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BACKFILL EXCAVATION CERTIFICATE <br />U � <br />Project Location Ro-Tile, 310 N. Cluff Ave Ind;, rn gg�48 <br />Owner Lavor Thompson Phone No. (209)369-4751 <br />Contractor Jim Thorpe Oil, Inc. Phone Vo. (209)368-6175 License No. 495699 <br />INDICATE METHOD OF BACK -FILL QUALITY ASSUR.AI:VCE <br />1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br />Y 2. Submission of verification, e.g., load ticket, within 30 days of project completion that one of thng mater <br />Elie followiials was <br />placed in the excavation in 12' lifts: <br />% A. Pea gravel --smooth, rounded material not more than one-half (1/2) inch in diameter <br />_ B. Crushed rock—self-compacting material not more than three -quavers (3/4) inch in cross sectional <br />measurement. (Use of crushed rock will not be permitted for backfill if contact will be made between <br />the backfill material and tanks/pipes made of poly resin glass or similar materials.) <br />DECLARATION <br />I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days of project completion, or submission of <br />verification that the select material described above will be placed at a minimum of five (55 cubic yards per 1000 gallon tank <br />displacement and that the entire excavation will be backfilled and compacted to insure compliance with the Uniform Building Code <br />Appendix Chapter 70. <br />Jim Thorne Oil Tn- by Ric.ha ri tat e <br />tiame— -(�: n[1 - <br />Con ctor <br />t• <br />tmature <br />Shall be the responsible managing employee on the license or authorized agent. <br />